OK, I’m jumping into this controversy about screening for breast cancer (mammograms, self exams, and the under- versus over-50 issue) a week late, but not because I haven’t been following the stories. It’s kind of hard to know how to talk about one’s breasts when one has the perspectives of both an economist and a woman. Health care is like no other economic good, and breasts are like no other part of a woman.

I’ve been listening to/reading all the arguments, and I am fascinated by all the chatter on this topic from male columnists/pundits (but should I be, really?…I mean, a chance for them to think about breasts as an important “public policy” issue?), but I found Howard Kurtz’s compilation of some very varied thoughts from female commentators most enlightening (and often entertaining) and provoking of my own opinions on the issue. I am one of those women in question–over 40 but under 50–who the U.S. Preventative Services Task Force now says shouldn’t bother with routine breast cancer screening, whether via mammograms or even self exams. Their judgment is that for the broad group of “women in their 40s” who do not have genetic predisposition for breast cancer (unfortunately I do), the “benefits” of such screening don’t outweigh the “harms” (costs).

To me this is a very curious (and odd) proposition. As explained in this New York Times article by Gina Kolata, the task force’s new position basically says that more information, even if free via self exams, can be a bad thing–not because the actual gathering of that information is risky, but because of how women might react to that information (with anxiety) or choose to act on that information (with potentially unnecessary surgery, perhaps with the encouragement of their doctors). My understanding is that the health risks from the (minimal) radiation produced by mammograms is (not coincidentally) very minimal. And of course there are no health risks from the process of self-examining one’s breasts. So the task force is not saying that the process of gathering the information is risky; they’re saying that how women might choose to use that information is risky. It’s a “save me from myself” argument.

But I still don’t get it. From a pure health perspective, the potential net benefits of early detection of breast cancer–even netting out the risks associated with the various surgical and chemical treatments for the disease–can be quite large. Not gathering the information increases the likelihood of “false negatives” and disease that goes untreated, the potential cost of which is death. The argument against gathering the information for those women who have lower risk on average (the under-50 crowd) is that it increases the likelihood of “false positives” and overreacting with treatment that is unnecessary, has potential complications, and which can be drastic–for example, cutting off a breast. But the decision about whether and how to act on a positive result is a woman’s personal decision, taken under the advisement of her physician who presumably helps her evaluate her own personal physical health risks (and emotional costs as well) of treating versus not treating. I have heard stories of women with such a strong genetic predisposition to breast cancer that they opt to have double mastectomies to preempt the disease, and I assume that those women have done their own personal cost-benefit calculation and decided that they (personally) were willing to “pay” two breasts in order to guarantee they would live a full life.

My own personal story about breast cancer screening has no such drama, although I’ve had routine mammograms since age 40 and on my own had found a small lump many years ago (which has never gone away but has also never grown) and have had a needle biopsy on it that I admit wasn’t a lot of fun. But it’s always been a no brainer for me, the only issue ever being “do I have time” or “can I remember” to get my annual mammogram–not whether getting it is worth the “risk” of learning something I might act upon or the “cost” of some temporary physical discomfort from seeking even better information (via the needle biopsy). I weigh the various “costs” or unpleasantries to myself against the benefits of detection, knowing that breast cancer runs in my family, but also understanding a lot about the potential complications of the potential “next step” of treatment–including watching my mom currently dealing with the complications of what had been expected to be an uncomplicated lumpectomy. (My mom is tough though; one of her mottos has always been “deal with it.”)

But would I choose for myself to purposely not know about my lump because I’m afraid of making a dumb decision about what to do about it?…

For me, my experience during my four full-term pregnancies and deciding whether or not to have an amniocentesis to screen for Down’s syndrome was much more a case of weighing the risks of getting the information against the possible benefits of having the information. The potential health “cost” of the procedure was the small risk of premature labor or even miscarriage, but the potential “benefit” of having the information was even smaller–because had I found out my baby had Down’s syndrome it would not have changed my carrying out the pregnancy but would have only helped me prepare (psychologically and practically) for having such a baby. (Given that calculation, I never had an amnio with any of my pregnancies, but opted for less informative, but also much less risky, screening methods instead.) My decision about the screening of my own pregnancies was about very personal costs weighed against very personal benefits and not some aggregate evaluation of the cost versus benefit to someone “like” me, in my broadly-defined “risk category”.

This strikes me as a fundamental policy challenge in trying to save money by using “comparative effectiveness” research; the government can present the public with evidence that on aggregate or average some procedure is not effective enough and hence should not be supported (and by that I mean not subsidized and not not allowed), but the subset of the population for whom it is effective (no matter how narrow) will surely balk at the suggestion, and policymakers will be very reluctant to take away any kind of health benefit from anyone who actually benefits from the benefit. I’ve suggested this before: wasteful spending is in the eye of the beneficiary.

Now, it’s true that this sort of aggregate calculation of costs versus benefits has to be done if we’re going to make any progress in paring back public health spending in as “smart” a way possible, and health care subsidies by drastically reducing personal out-of-pocket costs certainly work to tilt every insured individual’s own cost-benefit analysis in favor of doing too much screening and testing. I’m just saying “good luck” coming out with the recommendations on which procedures and protocols will no longer be government recommended and subsidized without hearing from “lobbyist advocates” representing every narrow subset of people for whom the personal cost-benefit analysis doesn’t jive with the aggregate one. It’s going to be awfully hard.

Finally, while we’re on the topic of breasts, I feel like pointing out the irony of the Senate health reform bill now having a tax on elective cosmetic surgery–including “boob jobs” presumably. (Yeah, I know–it’s just another way to tax only “rich” people.) Hopefully reconstructive surgery is not considered “elective” (I haven’t read over the legislative text), but I suppose there are “grey areas”…for example, if one used to be an A cup and after “reconstruction” is a C cup, then at least some of that is obviously “elective”–and maybe some “pro-rata” portion of the cost of surgery should be taxed! (I see this as a potential tax avoidance strategy giving tax planners “more material” to work with.)

I could tell more stories and make more analogies here, but I will resist the temptation lest the additional information have negative net benefit to you readers–at least on average.

8 Responses to “What’s Best for Our Breasts?”

From the start the ostensible rationale (or part thereof) that women in their 40s would generally be better off forgoing mammograms smelled to me like cover for the real rationale of cost containment via reducing/eliminating “waste” defined as benefits not worth the cost to taxpayers/society, in aggregate.

I don’t know enough about this particular issue to have a view of what I think is worth taxpayers and private insurance payers subsidizing (i.e., how many lives saved per dollar by starting mammograms at 40 rather at 50 is “worth it”), and I don’t wish to appear insensitive, but as a matter of general principle I think the response from many critics of this recommendation is unfortunate. Some critics have argued a moral absolute, as in “How can you possibly say it’s not ‘worth’ saving those lives that can be saved via mammograms for women in their 40s!!” Obviously this is not a rational way to think of either economics or morality, since resources are finite, and resources used to provide X level of Benefit Y to Group Z cannot be used to provide A level of Benefit B to Group C and/or to Group Z. And a response such as the above begs the question: What is the youngest age at which a girl/woman could possibly develop breast cancer that a mammogram could detect and which could then be treated? Is it 30? 25? If even one in ten million 25 year-old women fit that category, would critics who think per the above say we should start subsidizing mammograms at age 25?

It reminds me of the debate over raising the speed limit from 55mph to 65. Some people said “How can you possibly favor that when we know it will mean more highway deaths!!” And my answer was “ok, what if reducing it from 55 to 40mph would mean fewer highway deaths — would you insist on that change? And while we’re at it, why not eliminate all automotive deaths by banning automotive vehicles?

I took this debate as proving beyond a reasonable doubt that government is unable to make reasonable cost/benefit tradeoffs. I’ll stick to the mammogram point since it has costs (I agree with Diane’s point about self-exams — it really doesn’t make any sense at all). Let’s assume that the scientists did their work and concluded that the cost is not worth the benefit from these procedures. I certainly don’t understand the science behind it but that’s not the point for now.

The reaction of the government was to throw the scientists out the window immediately, not because their work was shoddy but because somewhere, someone is going to die as a consequence of this decision and that is something politicians cannot stomach. It’s one thing when government exercises indirect control over the healthcare system but quite another when the government will exercise direct control but determining which companies/policies can participate in the insurance exchange.

As I’ve said in other places, the real issue with HCR isn’t rationing, it’s cost explosion. The evil insurance companies have a real incentive to try to keep costs down. The government has none, to the contrary, its incentives are to minimize negative consequences regardless of costs. It’s Brooks’ argument about the speed limit (one I’ve used many times).

Government driven health care will, in my opinion, precipitate an economic crisis far faster than almost anything else I could imagine the government doing. I honestly don’t care what’s in the final bill. Simply look at the incentives by which government operates and you’ll have your answer

So much of this debate revolves around “hot button” issues - cancer, sexism, government involvement - and almost nothing about the science involved. All of the responses seem to be from breast cancer survivors (”you have no idea what I went through!”) or women writers (”how dare men weigh in on a woman’s health issue!”) but very few about whether the medical folks involved have done some sound work here, and their recommendations are good.

In other words: If we don’t believe in what our scientific community is telling us, who should we believe? After all, the current guidelines were established by another group of doctors - why did we believe them, and not what we’re hearing now?

Or, put another way, if we all agree that we should eliminate “unnecessary tests”, how (or who) should decide what is unnecessary?

This is why the health care debate has become so depressing. Everyone is in favor of reducing costs, so long as it doesn’t affect them.

Here’s my own personal story. Two years ago I had a seizure, and was diagnosed with a brain tumor. Fortunately, the tumor was malignant, and the surgery was successful. However, my doctor has advised that I get periodic MRI’s to make sure that the tumor does not reappear.

After my most recent MRI, my doctor said that an MRI would be necessary only once a year rather than twice. Extending the logic of the strident voices involved in the mammography debate, however, I should be outraged - how dare the doctor suggest that I don’t need MRI’s twice a year? After all, I have read other studies that say MRI’s at least twice a year are standard treatment.

But I don’t buy that, and neither should others. I think my doctor is saying, look, more tests don’t equal better care. More frequent MRI’s are not only unnecessary but also create needless anxiety on my part. If a tumor returns, it will likely be slow growing,and appropriate treatments can be figured out.

Re: The government has [no incentive to try to keep costs down], to the contrary, its incentives are to minimize negative consequences regardless of costs.

Perhaps you didn’t really mean to state the above in absolute terms, but it is an overstatement that overlooks the factors (and pressure points) that affect the political calculus and resulting legislation on this issue and in fiscal policy generally. Not to state the obvious, but basically I see three factors affecting the political calculus facing each member of Congress and the president (and I assume, cynically but I think realistically, that political calculus — i.e., impact on one’s chances of re-election and of advancement of one’s political career generally — is essentially the determinant of the policy choices of each).

(1) Political Benefit from Spending
(2) Political Cost from taxation
(3) Political Cost from deficits and debt.

We could add a fourth factor as likely impact on the economy and likelihood of voter perception that policy choices for 1, 2, and/or 3 caused/contributed to a good/bad economy, or we could just include that fourth factor as a component within each of 1,2, and 3.

The above may be fairly obvious, but I think it’s important to stay cognizant of all three factors and keep thinking of ways to influence the political calculus by doing what we can to move public opinion on all three fronts, generally reducing the popularity (political benefit) of higher spending and lower taxes, reducing the political cost of lower spending and higher taxes, and increasing the political cost of higher deficits and debt (with exceptions for the latter when temporarily higher deficits as stimulus are justifiable) and increasing the political benefit of deficit and debt reduction (fiscal responsibility). Those are the (hopefully) moving, or at least movable parts that, together, determine how soon and to what extent the federal government gets fiscally responsible.

This whole uproar is most discouraging - I keep hearing the word ‘hysteria’ in my mind…save us from ourselves because we’re such emotional creatures and will over react. It is condescending and paternalistic and reeks of a ‘Gov’t Knows Best’ attitude (the old, I’m from the Gov’t and I’m here to help). I find it scary in fact in terms of the direction this whole healthcare debate and legislation may go. I think it’s pretty clear the Gov’t doesn’t know best and usually doesn’t have a clue.

I have a strong breast cancer history in my family - my mother died 1yr ago after her 2nd recurrence (with a 20 yr hiatus in between). I’ve tested negative for the BRCA 1 & 2 genes, but there are many more we don’t know about. I am listed as high risk and so get a mammogram and an MRI annually - do I panic? no! I have known for years, been told for years, that there is a risk of false positives on mammograms and it was made abundantly clear to me with the MRIs - so I just figured (and still do) that I will get called back and not worry. And I do get called back and I don’t worry because each time it’s been negative - not that one time it may not be. But this whole argument against having the tests which were previously recommended, when there isn’t evidence of physical harm (e.g., too much radiation with too many mammograms, etc.), is foreboding to me…the gov’t is intruding into almost all aspects of our lives and we seem to be letting them without a fight.

Fair enough. I agree there is a modest downside from a government perspective to spending but it is a tragedy of the commons situation. The deficit/debt is diffuse and no particular program is responsible and thus on a program by program basis, there is very little reason to constrain spending even if, in aggregate too much spending or too little taxation can create issues

I’ve been much more conflicted about the study and have been somewhat disappointed about the tone of discussion and how quickly the politicians have thrown the scientists under the bus. One takeaway that seems to not be covered is that part of the reason for discouraging mammograms in women under 50 is that it is a lousy diagnostic tool for younger women.

As someone with a family history of breast cancer and the recipient of annual mammograms since the age of 30, I wish I had a better sense of this.
Despite the annual mammograms, reporting a lump to my doctor, a diagnostic mammogram and sonogram the radiologist was ready to send me away for another 6 months despite the very large (slow growing) tumor in my breast. I was diagnosed only after demanding a biopsy and the size wasn’t determined until I had an MRI.

Thus flip side to the many false positivies is the fact that mammograms regularly miss tumors in women under 50. A fact I wasn’t really aware of until being diagnosed and finding out my situation wasn’t that atypical.

Having a discussion about when to have a mammogram and shedding light on the fact that it is more art than science seems like a worthwhile conversation to be having. I’m willing to believe the scientists who say women should talk to their doctors and figure out when the best time to start or what the frequency of scanning should be.

Understanding how good or not good a medical tool is for different groups of people should be taken into consideration when moving forward in the current discussions of health care reform. Ideally studies can be done to understand the benefits and limits of technology and medicine. I’m hoping one consequence of this uproar isn’t a censoring of medical studies that have unpopular results.

This example demonstrates the unworkability of one-size-fits-all decisions on medical procedures.

Perceived breast cancer risks are different from woman to woman. They should be able to choose the level of coverage they want and pay for that level of coverage. Current reform proposals will quickly extinguish that choice by forcing all insurance to conform to one template.